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Updating the Beers Criteria for PotentiallyInappropriate Medication Use in Older AdultsResults of a US Consensus Panel of ExpertsDonna M. Fick, PhD, RN; James W. Cooper, PhD, RPh; William E. Wade, PharmD, FASHP, FCCP;Jennifer L. Waller, PhD; J. Ross Maclean, MD; Mark H. Beers, MDBackground: Medication toxic effects and drug-Results: This study identified 48 individual medica-
related problems can have profound medical and safety
tions or classes of medications to avoid in older adults
consequences for older adults and economically affect the
and their potential concerns and 20 diseases/conditions
health care system. The purpose of this initiative was to
and medications to be avoided in older adults with these
revise and update the Beers criteria for potentially inap-
conditions. Of these potentially inappropriate drugs, 66
propriate medication use in adults 65 years and older in
were considered by the panel to have adverse outcomes
Methods: This study used a modified Delphi method, aConclusions: This study is an important update of pre-
set of procedures and methods for formulating a group judg-
viously established criteria that have been widely used
ment for a subject matter in which precise information is
and cited. The application of the Beers criteria and other
lacking. The criteria reviewed covered 2 types of state-
tools for identifying potentially inappropriate medica-
ments: (1) medications or medication classes that should
tion use will continue to enable providers to plan inter-
generally be avoided in persons 65 years or older because
ventions for decreasing both drug-related costs and over-
they are either ineffective or they pose unnecessarily high
all costs and thus minimize drug-related problems.
risk for older persons and a safer alternative is available and(2) medications that should not be used in older personsknown to have specific medical conditions.Arch Intern Med. 2003;163:2716-2724TOXICEFFECTSofmedica- tocostthenation$8billionannually.5In
annually at a cost of $85 billion.6 Others
related problems to be $76.6 billion to am-
tem. Thirty percent of hospital admissions
bulatory care, $20 billion to hospitals, and
in elderly patients may be linked to drug-
$4 billion to nursing home facilities.2,7,8 If
related problems or drug toxic effects.1 Ad-
verse drug events (ADEs) have been linked
as a disease by cause of death, it would be
tients such as depression, constipation, falls,
tures.1,2 A 1997 study of ADEs found that
derly patients and other vulnerable popu-
Biostatistics (Dr Waller),Medical College of Georgia,
lations is one of the principal health care
enced an ADE and 29% required health care
quality and safety issues for this decade.
ment, or hospitalization) for the ADE.1 Some
CME course available at
two thirds of nursing facility residents have
www.archinternmed.com
ADEs over a 4-year period.3 Of these ADEs,
focused increased attention on finding so-
cation-related problems vastly exceed the
Pa (Dr Beers). The authorshave no relevant financial
findings of the Institute of Medicine (IOM)
in the care of older adults. There are many
lems in elderly patients, including the use of lists contain-ing specific drugs to avoid in the elderly and appropriate-
Below are the Beers criteria published in 1997. In parts 1 and 2, we are first asking you to rate your level of agreement on these 1997 criteria.
ness indexes applied by pharmacists or clinicians.1,10,11
Please answer the following questions regarding the use of medications in adults
Systematic review of the evidence-based literature on medi-
cation use in elderly patients is another approach to de-
Please give one of the following answers:
fining the problem, but the number of controlled studies
1=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree
on medication use in elderly patients is limited.0=Unable to offer an opinion
The use of consensus criteria for safe medication use
1) Propoxyphene (Darvon) and combination products (Darvon with ASA,
in elderly patients is one approach to developing reliable
Darvon-N, and Darvocet-N) should be avoided.
and explicit criteria when precise clinical information is
lacking. The two most widely used consensus criteria formedication use in older adults are the Beers criteria and
the Canadian criteria.12-14 The Beers criteria are based onexpert consensus developed through an extensive litera-
facility populations older than 65 years in the United
ture review with a bibliography and questionnaire evalu-
States. There were 3 main aims: (1) to reevaluate the
ated by nationally recognized experts in geriatric care,
1997 criteria to include new products and incorporate
clinical pharmacology, and psychopharmacology using a
new information available from the scientific literature,
modified Delphi technique to reach consensus. The
(2) to assign or reevaluate a relative rating of severity
Beers criteria have been used to survey clinical medica-
for each of the medications, and (3) to identify any new
tion use, analyze computerized administrative data sets,
conditions or considerations not addressed in the 1997
and evaluate intervention studies to decrease medication
problems in older adults. The Beers criteria were alsoadopted by the Centers for Medicare & Medicaid Ser-
vices (CMS) in July 1999 for nursing home regulation.Previous studies have shown these criteria to be useful
There were 5 phases in the data collection for this study: (1)
in decreasing problems in older adults.15-19 These crite-
the review of the literature, (2) creation and mailing of the round1 questionnaire, (3) creation of the second-round question-
ria, though controversial at times, have been widely used
naire based on round 1 and expert panel feedback, (4) con-
over the past 10 years for studying prescribing patterns
vening of the expert panel and panel responses to the second-
within populations, educating clinicians, and evaluating
round questionnaire, and (5) completion and analysis of a third
health outcomes, cost, and utilization data.20-23
and final mailed questionnaire that measured the severity rat-
A recently published study of potentially inappro-
ings of the PIMs to create the final revised list.
priate medication (PIM) use with the Beers criteria in a
The criteria reviewed covered 2 types of statements: (1)
Medicare-managed care population found a PIM preva-
medications or medication classes that should generally be
lence of 23% (541/2336). Those receiving a PIM had sig-
avoided in persons 65 years or older because they are either
nificantly higher total, provider, and facility costs and a
ineffective or they pose unnecessarily high risk for older per-
higher mean number of inpatient, outpatient, and emer-
sons and a safer alternative is available and (2) medicationsthat should not be used in older persons known to have spe-
gency department visits than comparisons after control-
cific medical conditions. The 2 statements each used a 5-point
ling for sex, Charlson Comorbidity Index, and total num-
Likert scale and ask respondents to rate their agreement or dis-
ber of prescriptions.20 Other studies have found that specific
agreement with the statement from strongly agree (1) to
PIMs such as nonsteroidal anti-inflammatory drugs
strongly disagree (5), with the midpoint (3) expressing equivo-
(NSAIDs) and benzodiazepines have been associated with
cation. The second type of question asked the respondents to
adverse outcomes and increased costs.18 In contrast, a re-
evaluate the medication appropriateness given certain condi-
cent study on the relationship between inappropriate drug
tions or diagnoses (Figure). All questions included an option
use, functional status decline, and mortality in 3234 pa-
to not answer if the respondent did not feel qualified to
tients from the Duke cohort did not find an association
answer. This methodology was similar to that used by Beers et
with mortality and inappropriate drug use as determined
al13 in the creation of the first 2 iterations of the criteria. Themethodology used in the third iteration of the Beers criteria
by the Beers criteria after controlling for covariates.24
only differed in the number of panelists (13 in 1991; 6 in
In summary, these criteria have been used exten-
1997; and 12 in 2002) and the use of a third-round survey for
sively for evaluating and intervening in medication use
the severity ratings, which was done (in person) in the 1997
in older adults over the past decade. However, with the
continuous arrival of new drugs on the market, in-creased knowledge about older drugs, and removal of
RESEARCH DESIGN
older drugs from the market, these criteria must be up-dated on a regular basis to remain useful. Since the cri-
The modified Delphi method is a technique to arrive at a group
teria were published in 1997, there has been an increase
consensus regarding an issue under investigation that was origi-
in the number of scientific studies addressing drug use
nally developed at the RAND Corporation (Santa Monica, Calif)by Olaf Helmer and Norman Dalkey.25 The Delphi method is a
and appropriateness in older adults, but there is still a
set of procedures and methods for formulating a group judg-
lack of controlled studies in the older population and par-
ment for a subject matter in which precise information is lack-
ticularly in patients older than 75 years and patients with
ing (such as medication use in older adults). The Delphi method
provides a means to reach consensus within a group of ex-
The purpose of this initiative was to revise and
perts. The method relies on soliciting individual (often anony-
update the Beers criteria for ambulatory and nursing
mous) answers to written questions by survey or other type of
communication. A series of iterations provides each indi-
years and older. The second-round survey included the state-
vidual with feedback on the responses of the others in the group.
ments included from round 1 and any statements added by the
The final responses are evaluated for variance and means to de-
experts from the first round. In the second round and the face-
termine which questions the group has reached consensus about,
to-face meeting, the respondents were given information about
their answers and the anonymous answers of the other mem-bers of the group and were given the opportunity to recon-
LITERATURE REVIEW
After analyzing the responses from the first round of the
The selection of articles for formulating the survey involved 3
survey, we examined each question for inclusion or exclusion
steps and was phase 1 of the study. First, we identified litera-
in the revised criteria or for further consideration in the sec-
ture published since January 1994 in English, describing or
ond round of the survey. We calculated the mean rating and
analyzing medication use in community-living (ambulatory)
corresponding 95% confidence interval (CI) of each state-
older adults and older adults living in nursing homes. From
ment or dosing question collected from the first round of the
that, we created a table and bibliography. We used MEDLINE,
survey. Those statements whose upper limit of the 95% CI
searching with the following key terms adverse drug reactions,
was less than 3.0 were included in the updated criteria. Those
adverse drug events, medication problems, and medications and
statements or dosing questions whose lower limit of the 95%
elderly for all relevant articles published between January 1994
CI was greater than 3.0 were excluded from the updated cri-
and December 2000. Second, we hand searched and identified
teria. Statements whose 95% CI included the value of 3.0 were
additional references from the bibliographies of relevant
included for further determination in the second-round face-
articles. Third, all the panelists were invited to add references
and articles after the first survey to add to the literature review.
The face-to-face meeting was convened on December 10,
Each study was systematically reviewed by 2 investigators
2001, in Atlanta, Ga. Each panel member was given the re-
using a table to outline the following information: type of
sults of the first-round survey and the added medications (from
study design; sample size; medications reviewed; summary of
the other panel members) to review approximately 10 days be-
results and key points; quality, type and category of medica-
fore the meeting. For statements that needed further exami-
tion addressed; and severity of the drug-related problem.
nation (neither included or excluded during round 1), each raterwas given his or her previous rating and the mean rating of the
EXPERT PANEL SELECTION
group of experts in the second survey.
Any additional statements or dosing questions that had
The panel of members were invited to participate via letter by
been made on the open-ended portion of the first round of the
the 4 investigators and a consultant and represented a variety of
survey by any expert was included in the survey for the sec-
experience and judgment including extensive clinical practice,
ond round. Forty-four questions were added by expert panel-
extensive publications in this area, and/or senior academic rank.
ists during round 1 of the survey, and 9 questions were added
They were also chosen to represent acute, long-term, and com-
during the round 2 in-person survey and voted on during the
munity practice settings with pharmacological, geriatric medi-
in-person meeting. These questions/medications made up part
cine, and psychiatric expertise. Lastly, they were selected from
5 of the survey. Twenty-four questions from parts 3 and 4 had
geographically diverse parts of the United States. We initially in-
95% CIs greater than 3.0 after the round 1 survey. During the
vited (via regular mail) 16 potential participants with nation-
second-round face-to-face meeting, the group debated these re-
ally and/or internationally recognized expertise in psychophar-
maining statements and then rerated them using the same Likert
macology, pharmacoepidemiology, clinical geriatric
scale. The mean rating and 95% CI were calculated. The tech-
pharmacology, and clinical geriatric medicine to complete our
nique used for the first round for inclusion or exclusion of the
survey. Our response rate for the initial invitation to participate
statement or dosing question in the updated criteria was used.
as a panelist was 75% (12/16). Our final panel thus consisted of
Those statements whose 95% CI included 3.0 were excluded
12 experts who completed all rounds of the survey.
from the updated criteria. Lastly, in January 2002, we sur-veyed panelists on a 5-point scale for the severity of the poten-
DATA COLLECTIONAND ANALYSIS
We used the systematic review of the literature to construct thefirst round questionnaire. The first-round survey contained
The final criteria are listed in Table 1 and Table 2. Table
4 sections. Parts 1 and 2 reviewed the latest 1997 criteria. Parts
1 contains 48 individual medications or classes of medi-
3 and 4 were medications added for the 2002 update for medi-cations alone (part 3) and medications considering diagnoses
cations to avoid in older adults and their potential con-
and conditions. Parts 3 and 4 included 29 new questions about
cerns. Table 2 lists 20 diseases or conditions and medi-
medications or medication classes and conditions. The last ques-
cations to be avoided in older adults with these conditions.
tion in part 4 asked panel members to add medications to the
Sixty-six of these potentially inappropriate drugs were
list. The panel was then surveyed via Delphi technique to de-
considered by the panel to have adverse outcomes of high
termine concordance/consensus with the round 1 survey and
severity. New conditions and diagnoses that were ad-
invited to add additional medications prior to and during the
dressed this time included depression, cognitive impair-
ment, Parkinson disease, anorexia, and malnutrition, syn-
We created the second and third questionnaires (severity
drome of inappropriate antidiuretic hormone secretion,
ratings) from panel input and the results of the previous round
survey. We completed all mailed and face-to-face rounds be-tween October 2001 and February 2002. We constructed the
A total of 15 medications/medication classes were
questionnaire statements according to the original Beers cri-
dropped or modified from the 1997 to the 2002 update from
teria published in 1991 and the updated criteria published in
the round 1 survey. Most of the medications dropped since
1997. The instructions accompanying the survey asked the re-
1997 were those that were associated with diagnoses or con-
spondents to consider the use of medications only in adults 65
ditions. The following medications were voted to be dropped
Table 1. 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of Diagnoses or ConditionsSeverity Rating(High or Low)
Propoxyphene (Darvon) and combination products
Offers few analgesic advantages over acetaminophen, yet has the adverse
(Darvon with ASA, Darvon-N, and Darvocet-N)
Of all available nonsteroidal anti-inflammatory drugs, this drug produces
Narcotic analgesic that causes more CNS adverse effects, including
confusion and hallucinations, more commonly than other narcoticdrugs. Additionally, it is a mixed agonist and antagonist.
One of the least effective antiemetic drugs, yet it can cause extrapyramidal
Muscle relaxants and antispasmodics: methocarbamol
Most muscle relaxants and antispasmodic drugs are poorly tolerated by
(Robaxin), carisoprodol (Soma), chlorzoxazone (Paraflex),
elderly patients, since these cause anticholinergic adverse effects,
metaxalone (Skelaxin), cyclobenzaprine (Flexeril), and
sedation, and weakness. Additionally, their effectiveness at doses
oxybutynin (Ditropan). Do not consider the extended-release
tolerated by elderly patients is questionable.
This benzodiazepine hypnotic has an extremely long half-life in elderly
patients (often days), producing prolonged sedation and increasing theincidence of falls and fracture. Medium- or short-actingbenzodiazepines are preferable.
Amitriptyline (Elavil), chlordiazepoxide-amitriptyline (Limbitrol),
Because of its strong anticholinergic and sedation properties, amitriptyline
is rarely the antidepressant of choice for elderly patients.
Because of its strong anticholinergic and sedating properties, doxepin is
rarely the antidepressant of choice for elderly patients.
This is a highly addictive and sedating anxiolytic. Those using
meprobamate for prolonged periods may become addicted and mayneed to be withdrawn slowly.
Doses of short-acting benzodiazepines: doses greater than
Because of increased sensitivity to benzoadiazepines in elderly patients,
lorazepam (Ativan), 3 mg; oxazepam (Serax), 60 mg;
smaller doses may be effective as well as safer. Total daily doses should
alprazolam (Xanax), 2 mg; temazepam (Restoril), 15 mg;
rarely exceed the suggested maximums.
Long-acting benzodiazepines: chlordiazepoxide (Librium),
These drugs have a long half-life in elderly patients (often several days),
chlordiazepoxide-amitriptyline (Limbitrol)
producing prolonged sedation and increasing the risk of falls and
clidinium-chlordiazepoxide (Librax), diazepam (Valium),
fractures. Short- and intermediate-acting benzodiazepines are preferred
quazepam (Doral), halazepam (Paxipam), and chlorazepate
Of all antiarrhythmic drugs, this is the most potent negative inotrope and
therefore may induce heart failure in elderly patients. It is also stronglyanticholinergic. Other antiarrhythmic drugs should be used.
Digoxin (Lanoxin) (should not exceed Ͼ0.125 mg/d except when
Decreased renal clearance may lead to increased risk of toxic effects.
Short-acting dipyridamole (Persantine). Do not consider the
long-acting dipyridamole (which has better properties than theshort-acting in older adults) except with patients with artificialheart valves
Methyldopa (Aldomet) and methyldopa-hydrochlorothiazide
May cause bradycardia and exacerbate depression in elderly patients.
May induce depression, impotence, sedation, and orthostatic hypotension.
It has a prolonged half-life in elderly patients and could cause prolonged
hypoglycemia. Additionally, it is the only oral hypoglycemic agent thatcauses SIADH.
Gastrointestinal antispasmodic drugs: dicyclomine (Bentyl),
GI antispasmodic drugs are highly anticholinergic and have uncertain
hyoscyamine (Levsin and Levsinex), propantheline
effectiveness. These drugs should be avoided (especially for
(Pro-Banthine), belladonna alkaloids (Donnatal and others),
Anticholinergics and antihistamines: chlorpheniramine
All nonprescription and many prescription antihistamines may have potent
(Chlor-Trimeton), diphenhydramine (Benadryl), hydroxyzine
anticholinergic properties. Nonanticholinergic antihistamines are
(Vistaril and Atarax), cyproheptadine (Periactin), promethazine
preferred in elderly patients when treating allergic reactions.
(Phenergan), tripelennamine, dexchlorpheniramine(Polaramine)
May cause confusion and sedation. Should not be used as a hypnotic, and
when used to treat emergency allergic reactions, it should be used inthe smallest possible dose.
Ergot mesyloids (Hydergine) and cyclandelate (Cyclospasmol)
Have not been shown to be effective in the doses studied.
Doses Ͼ325 mg/d do not dramatically increase the amount absorbed but
greatly increase the incidence of constipation.
All barbiturates (except phenobarbital) except when used to
Are highly addictive and cause more adverse effects than most sedative or
Table 1. 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of Diagnoses or Conditions (cont)Severity Rating(High or Low)
Not an effective oral analgesic in doses commonly used. May cause
confusion and has many disadvantages to other narcotic drugs.
Has been shown to be no better than aspirin in preventing clotting and
may be considerably more toxic. Safer, more effective alternativesexist.
Immediate and long-term use should be avoided in older persons, since
a significant number have asymptomatic GI pathologic conditions.
These drugs have potential for causing dependence, hypertension,
Long-term use of full-dosage, longer half-life,
Have the potential to produce GI bleeding, renal failure, high blood
non–COX-selective NSAIDs: naproxen (Naprosyn, Avaprox,
and Aleve), oxaprozin (Daypro), and piroxicam (Feldene)
Long half-life of drug and risk of producing excessive CNS stimulation,
sleep disturbances, and increasing agitation. Safer alternatives exist.
Long-term use of stimulant laxatives: bisacodyl (Dulcolax),
cascara sagrada, and Neoloid except in the presence of opiateanalgesic use
Associated with QT interval problems and risk of provoking torsades de
pointes. Lack of efficacy in older adults.
Causes more sedation and anticholinergic adverse effects than safer
May cause orthostatic hypotension. Safer alternatives exist.
Potential for renal impairment. Safer alternatives available.
Potential for hypotension, dry mouth, and urinary problems.
Methyltestosterone (Android, Virilon, and Testrad)
Potential for prostatic hypertrophy and cardiac problems.
Greater potential for CNS and extrapyramidal adverse effects.
CNS and extrapyramidal adverse effects.
Short acting nifedipine (Procardia and Adalat)
Potential for hypotension and constipation.
Potential for orthostatic hypotension and CNS adverse effects.
Potential for aspiration and adverse effects. Safer alternatives available.
CNS adverse effects including confusion.
Potential for hypertension and fluid imbalances. Safer alternatives
Concerns about cardiac effects. Safer alternatives available.
Amphetamines (excluding methylphenidate hydrochloride
Evidence of the carcinogenic (breast and endometrial cancer) potential
of these agents and lack of cardioprotective effect in older women.
Abbreviations: CNS, central nervous system; COX, cyclooxygenase; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of
inappropriate antidiuretic hormone secretion.
or modified from the criteria by the panelists since the 1997
that are off the market. The expert panelists could not
publication: phenylbutazone, oxybutynin chloride, ␤-block-
reach consensus about adding questions regarding set-
ers, corticosteroids with persons with diabetes; sedative-
ting maximum dosages for sedative-hypnotics, antipsy-
hypnotics in persons with chronic obstructive pulmonary
chotics, selective serotonin reuptake inhibitors, and tri-
disease; ␤-blockers in persons with asthma; ␤-blockers in
cyclic antidepressants that do not have specific
persons with peripheral vascular disorder; ␤-blockers in
recommendations from the manufacturer, though there
persons with syncope and falls; narcotics in persons with
was agreement that consideration of changes in pharma-
bladder outflow obstruction; and theophylline sodium gly-
cokinetics were important in older patients in prevent-
cinate in persons with insomnia (Table 3). Oxybutinin
ing problems caused by excessive dosages and usage.
was modified by not including the extended-release for-
This update also includes several medications that have
mula, which the panel believed had fewer adverse
new information or have come to market since the last study
effects. Reserpine was changed to be avoided only at
of the Beers criteria was published (1997), including se-
doses greater than 0.25 mg, and disopyramide phosphate
lective serotonin reuptake inhibitors, amiodarone, and
avoidance now only refers to the non–extended release
fluoxetine hydrochloride. The panel also voted to add me-
formulation. New information about ␤-blockers in
thyltestosterones, amphetamines, and bupropion hydro-
elderly patients led the panel to drop this class of drugs
chloride to the list of medications to be avoided in older
from the list. The other criteria dropped involved use of
adults. Tables 1 and 2 state why medications were added
drugs in the setting of a comorbid condition or drugs
since 1997, and Table 3 summarizes all the changes to the
Table 2. 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering Diagnoses or ConditionsSeverity RatingDisease or Condition(High or Low)
Disopyramide (Norpace), and high sodium content drugs
Negative inotropic effect. Potential to promote
(sodium and sodium salts [alginate bicarbonate,
fluid retention and exacerbation of heart
biphosphate, citrate, phosphate, salicylate, and sulfate])
Phenylpropanolamine hydrochloride (removed from the
market in 2001), pseudoephedrine; diet pills, and
secondary to sympathomimetic activity.
NSAIDs and aspirin (Ͼ325 mg) (coxibs excluded)
May exacerbate existing ulcers or produce
Clozapine (Clozaril), chlorpromazine (Thorazine),
thioridazine (Mellaril), and thiothixene (Navane)
Aspirin, NSAIDs, dipyridamole (Persantin), ticlopidine
May prolong clotting time and elevate INR
resulting in an increased potential forbleeding.
Anticholinergics and antihistamines, gastrointestinal
May decrease urinary flow, leading to urinary
antispasmodics, muscle relaxants, oxybutynin
(Ditropan), flavoxate (Urispas), anticholinergics,antidepressants, decongestants, and tolterodine (Detrol)
␣-Blockers (Doxazosin, Prazosin, and Terazosin),
anticholinergics, tricyclic antidepressants (imipramine
hydrochloride, doxepin hydrochloride, and amitriptylinehydrochloride), and long-acting benzodiazepines
Tricyclic antidepressants (imipramine hydrochloride,
Concern due to proarrhythmic effects and ability
doxepin hydrochloride, and amitriptyline hydrochloride)
Decongestants, theophylline (Theodur), methylphenidate
Concern due to CNS stimulant effects.
Metoclopramide (Reglan), conventional antipsychotics, and
Barbiturates, anticholinergics, antispasmodics, and muscle
Concern due to CNS-altering effects.
relaxants. CNS stimulants: dextroAmphetamine(Adderall), methylphenidate (Ritalin), methamphetamine(Desoxyn), and pemolin
Long-term benzodiazepine use. Sympatholytic agents:
May produce or exacerbate depression.
methyldopa (Aldomet), reserpine, and guanethidine(Ismelin)
CNS stimulants: DextroAmphetamine (Adderall),
Concern due to appetite-suppressing effects.
methylphenidate (Ritalin), methamphetamine (Desoxyn),pemolin, and fluoxetine (Prozac)
Short- to intermediate-acting benzodiazepine and tricyclic
antidepressants (imipramine hydrochloride, doxepin
function, syncope, and additional falls.
hydrochloride, and amitriptyline hydrochloride)
SSRIs: fluoxetine (Prozac), citalopram (Celexa),
fluvoxamine (Luvox), paroxetine (Paxil), and sertraline(Zoloft)
May stimulate appetite and increase weight gain.
Long-acting benzodiazepines: chlordiazepoxide (Librium),
CNS adverse effects. May induce respiratory
chlordiazepoxide-amitriptyline (Limbitrol),
clidinium-chlordiazepoxide (Librax), diazepam (Valium),
quazepam (Doral), halazepam (Paxipam), andchlorazepate (Tranxene). ␤-blockers: propranolol
Calcium channel blockers, anticholinergics, and tricyclic
antidepressant (imipramine hydrochloride, doxepinhydrochloride, and amitriptyline hydrochloride)
Abbreviations: CNS, central nervous systems; COPD, chronic obstructive pulmonary disease; INR, international normalized ratio; MAOIs, monoamine oxidase
inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptakeinhibitors.
Beers criteria since 1997, including medications that were
cited.16,20,22,23,26-29 The application of the Beers criteria and
other tools for identifying PIM use will continue to en-able providers to plan interventions for decreasing both
drug-related costs and overall costs and thus minimizedrug-related problems.9,30 Such tools are also vitally im-
This study is an important update of previously estab-
portant to managed care organizations, pharmacy ben-
lished criteria that have been widely used and
efit plans, and both acute and long-term health care in-
Table 3. Summary of Changes From 1997 Beers Criteria to New 2002 CriteriaMedicines Modified Since 1997 Beers Criteria
2. Extended-release oxybutynin (Ditropan XL)†
4. Short-acting dipyridamole (Persantine)‡
Medicines Dropped Since 1997 Beers Criteria
6. Metoclopramide (Reglan) with seizures or epilepsy
7. Narcotics with bladder outflow obstruction and narcotics with constipation
2. Recently started corticosteroid therapy with diabetes
3. ␤-Blockers with diabetes, COPD or asthma, peripheral vascular
11. Bethanechol chloride with bladder outflow obstruction
5. Potassium supplements with gastric or duodenal ulcers
Medicines Added Since 1997 Beers Criteria
17. Amphetamines (excluding methylpenidate and anorexics)
19. Short-acting nifedipine (Procardia and Adalat)
21. Stimulant laxatives may exacerbate bowel dysfunction (except in presence
of chronic pain requiring opiate analgesics)
9. Methyltestosterone (Android, Virilon, and Testrad)
23. Non–COX-selective NSAIDs (naproxen [Naprosyn], oxaprozin, and
26. Long-acting benzodiazepines: chlordiazepoxide (Librium),
33. Decongestants with bladder outflow obstruction
chlordiazepoxide-amitriptyline (Limbitrol),
34. Calcium channel blockers with constipation
clidinium-chlordiazepoxide (Librax), diazepam (Valium),
35. Phenylpropanolamine with hypertension
quazepam (Doral), halazepam (Paxipam), and chlorazepate
36. Bupropion (Wellbutrin) with seizure disorder
(Tranxene) with COPD, stress incontinence, depression, and falls
38. Metoclopramide (Reglan) with Parkinson disease
28. Anticholinergics with stress incontinence
39. Conventional antipsychotics with Parkinson disease
29. Tricyclic antidepressants (imipramine hydrochloride, doxepine
40. Tacrine (Cognex) with Parkinson disease
hydrochloride, and amitriptyline hydrochloride) with syncope or
41. Barbiturates with cognitive impairment
42. Antispasmodics with cognitive impairment
30. Short to intermediate and long-acting benzodiazepines with
43. Muscle relaxants with cognitive impairment
44. CNS stimulants with anorexia, malnutrition,
31. Clopidogrel (Plavix) with blood-clotting disorders receiving
32. Tolterodine (Detrol) with bladder outflow obstruction
Abbreviations: CNS, central nervous system; COPD, chronic obstructive pulmonary disease; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory
drugs; SSRIs, selective serotonin reuptake inhibitors.
*Reserpine in doses Ͼ0.25 mg was added to the list.†Ditropan was modified to refer to the immediate-release formulation only and not Ditropan XL and iron supplements was modified to include only ferrous
‡Do not consider the long-acting dipyridamole, which has better properties than the short-acting dipyridamole in older adults (except with patients with artificial
stitutions. However, to remain useful, criteria must be
at times as too simplistic and limiting the freedom of phy-
regularly updated and must take into account the ever-
sicians to prescribe.31-35 However, we believe that thought-
increasing, evidence-based literature in the area of medi-
ful application of the updated 2002 Beers criteria and other
tools for identifying PIM use can enable providers and in-
The argument in favor of using explicit criteria in pre-
surers to plan interventions aimed at decreasing drug-
scribing practice is overwhelming: improvements in thera-
related costs and overall health care costs, while reducing
peutic practices and reduction in medication-related ADEs
ADE-related admissions in elderly patients9,30 and improv-
will increase the quality of care and enhance patient out-
ing care. The updated Beers criteria will enable everyone
come at the same time as optimizing resource utilization
from individual physicians to health care systems to in-
and promoting fiscal prudence. These criteria, though
tegrate the new criteria-based prescribing recommenda-
widely used, have been controversial because of their adop-
tions into their organic, mechanical, and electronic infor-
tion by nursing home regulators and have been criticized
The proponents of explicit criteria and evidence-
clinical need remains a challenge for the information sys-
based prescribing are among the biggest players in the
tems and information technology engineer, the behav-
health care industry: the IOM, the CMS, the Agency for
ior change specialist, and the medical profession.42
Healthcare Research and Quality (AHRQ), and the Ameri-can Association of Health Plans (AAHP), to name but
Accepted for publication March 28, 2003.
four.36,37 Indeed, finding a voice of dissent is challeng-
This research was supported by a grant from the Medi-
ing. In “Crossing the Quality Chasm” the IOM38 pre-
cal College of Georgia (Augusta) and University of Geor-
sents a template for the future, when the traditional val-
gia (Athens) Combined Intramural Grant Program.
ues of physician integrity, altruism, knowledge, skill, and
We thank Judy Johnson, MAT, R. C. Robinson, BS, and
dedication to lifelong patient care are seamlessly inte-
Alison Maclean, BA, for assistance with data management
grated into an information era of point-of-care, comput-
and manuscript preparation. We acknowledge the follow-
erized decision support that facilitates appropriate care
ing individuals for contributing their expertise to this study
using the available resources. The updated Beers crite-
as panel members: Maude Babington, PharmD (Babington
ria are one component of that movement, enabling all
Consulting, LLC, Boulder, Colo); Manju T. Beier, PharmD
parties, from providers to insurers, to integrate our rec-
(The University of Michigan, Ann Arbor); Richard W. Be-
ommendations into their clinical information systems.sdine, MD (Brown University, Providence, RI); Jack Fin-
Given the aforementioned, there appears to be a po-
cham, PhD (University of Kansas, Lawrence); F. Michael
tential niche for the Beers criteria in fulfilling the mis-
Gloth III, MD (Johns Hopkins University School of Medi-
sions of the IOM, CMS, AHRQ, and AAHP. However,
cine, Baltimore, Md); Thomas Jackson, MD (Medical Col-
translating research into measurable quality improve-
lege of Georgia, Augusta); John E. Morley, MD (Saint Louis
ment may be more challenging. In the first instance, de-
University Health Sciences Center, St Louis, Mo); Becky
spite the much-lauded public statements about quality
Nagle, PharmD, BCPC (Medco Health Solutions, Franklin
by many (including the above organizations), there is
Lakes, NJ); Todd Semla, PharmD, MS (Evanston North-
widespread recognition that perhaps cost containment
western Healthcare, Evanston, Ill); Mark A. Stratton,
is the principal driver of change in the health care world.39
PharmD (University of Oklahoma, Oklahoma City); An-
Individual health care providers and organizations will
drew D. Weinberg, MD (Emory University School of Medi-
demand objective evidence that implementation of the
updated Beers criteria (or, indeed, other inappropriate
Corresponding author and reprints: Donna M. Fick,
medication guides) will result in objective, quantifiable
PhD, RN, Center for Health Care Improvement, Depart-
improvements in the clinical effectiveness and cost-
ment of Medicine, Medical College of Georgia, HB 2010, 1467
effectiveness of health care services. To date, despite ex-
Harper St, Augusta, GA 30912 (e-mail: [email protected]).
tensive literature demonstrating association—based onretrospective studies on administrative data—there is an
absence of rigorous, prospective research in this field. We(D.M.F., J.L.W., and J.R.M.) are completing a random-ized controlled study among a Medicare managed care
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sion and melancholia. J Affect Disord. 2001;63:93-102.Error in “Results” Section. In the Original Investigation by Fick et al titled“Updating the Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults,” published in the December 8/22 issue of the ARCHIVES (2003;163:2716-2724), an error occurred in the “Results” section on page 2720. Thesecond full sentence in the left column should have read “Reserpine was changedto be avoided only at doses greater than 0.25 mg, and disopyramide phosphateavoidance now only refers to the non–extended release formulation.” This cor-rection was made previously to online versions of this article.
(REPRINTED) ARCH INTERN MED/ VOL 164, FEB 9, 2004
2004 American Medical Association. All rights reserved.